1. Intermediate Care In Wales April 2008! Dr Pradeep B Khanna MBE MB FRCP- Consultant Physician/Chief of Staff, Community Services & COTE/ Lead Clinician Stroke Care

2. Intermediate Care in England Prof JOHN YOUNG Head, Academic Unit of Elderly Care & Rehabilitation Bradford Hospitals & Leeds University, UK john.young@bradfordhospitals.nhs.uk

3. Why do we need intermediate care ? Provide high quality service with better outcomes Too many older people Too many older people in hospital Too many of the wrong sorts of older people in hospital Demand to contain or reduce hospital costs = reduce length of stay An opportunity to design better services for older people

4. PROFESSIONAL RESPONSE TO INTERMEDIATE CARE “I’m going to keep my eyes tightly closed until this nasty intermediate care thing has blown over”

6. Welsh Definition of Intermediate Care STANDARD – Intermediate Care is established as a mainstream, integrated system of health and social care which: Enables older people to maintain their health, independence and home life; Promptly identifies and respond to older peoples health and social care needs, helping to avoid crisis management and unnecessary hospital or care home admission; Enables timely discharge or transfer, promoting effective rehabilitation and independence. National Service Framework for Older People in Wales. (March 2006)

7. AIMS OF INTERMEDIATE CARE 1.Responding to, or averting, a crisis Admission prevention 2.Active rehabilitation following an acute hospital stay Early discharge 3.Where long-term care is being considered Prevention of long term care 4.Chronic long term Conditions Management. Expert patient programme and assistive technology

8. Service Characteristics of Welsh Intermediate Care Integrated approach to local planning, commissioning, delivery and evaluation Early discharge or admission prevention Actions based on rapid comprehensive unified assessment and response Maximises independence with force on rehabilitation Multi-agency working –integrated teams supported by sound, network and governance All components needed

9. Development of Intermediate Care Intermediate care beds People receiving intermediate care Intermediate care places 1999 4,442 132,000 7,149 2004 8,697 331,721 17,339

10. HOW MUCH INTERMEDIATE CARE DO I NEED ?

11. 45%

12. I.C. CAPACITY Needs assessment survey in Medway & Swale (pop=372,000) Census of pts in DGH+CHs+DH+rehab centre+IC services N=871 pts….of whom 395 (45%) in need of an IC service Clinical futures (gwent) inpatients 634/2082 (30.45%) I.C – 35% NHS facilities; 65% community

13. A RATHER SCARY BUSINESS 45% is a very big number! BUT, although size matters It’s NOT the only thing that matters

14. Summary of RCT Evidence for Intermediate Care Service Models (*Cochrane Reviews) Nurse-led Units* 10 trials ? Increase mortality (n=1,896) Increase overall LOS Day hospital* 12 trials Effective but expensive (n=2,867) Care homes 1 trial Shift costs to social care (n=165) Community Hosp 1 trialCost effective (n=490) Hosp-at-home* > 20 trials 3 separate Cochrane reviews

15. Hospital-at-Home: definition……… HaH = “….a service that provides active treatment by health care professionals, in the patient’s home, of a condition that would otherwise require acute hospital in- patient care, always for a limited period.” Cochrane definition, 2005 Combination of personal support & rehabilitation care Hospital care but delivered in the person’s own home !!!

16. Hospital-at-Home v In-patient Care (RCTs) Reduction in hospital stay (days) for elderly medical patients Early Discharge Services Control HaHDiff Bristol, UK n=241 3 mth 5039-11 (-22%) Gloucester, UK n=60 6 mth 11 5-6 (-55%) Oxford, UK n=96 3mth13.212.8-0.4 (-3%) London, UK n=54 12mth3514-21 (-60%) Nottingham, UK n=370 12 mth 2112-9 (-43%) But does this mean we are going to save money?

17. Hospital-at-Home Intermediate Care: Three conclusions………………………. 2. Flexible type of service: Different patients groups Early discharge and admission avoidance 3. Can reduce hospital bed use improve outcome (better ADL’s, reduce whole system costs and be cost-effective system of care 1. Limited RCT evidence base BUT…. not always……….

18. Evaluation of Leeds city-wide I.C. service: “Before” & “After” study (n=1,648) Frail patients: acute E.C. admissions with “geriatric giants” Only 29% pts received I.C. over 12 months NEADLI.C. ptsControls score changes(n=246)(n=246) 3months:-1.39 6months:-1.92 12months:-2.79 -2.44 -2.63 -3.26 Beds days used over 12 months = +8 days for I.C. group Young et al. Age & Ageing 2005; 34: 577

19. Bradford, UK Community Hospital Study Single centre RCT (n=220) of CH v Acute Hospital Geriatric Dept care for patients with “Geriatric Syndromes” CH was locality-based (population of 92,000) CH provided I.C. as an early discharge service Greater functional independence at six months Improved patient experience of hospital care Findings: Cost-effective Brit Med Journal 2005 & 2006

20. Early discharge service using a community hospital: the sooner the better? Secondary, pre-planed analysis (n=220) Changes in Nottingham extended ADL baseline to 6 months NEADL SCORES Early transfer < 2 days [n=73] Late transfer >2 days [n=49] Gen Hosp [n=69] Median (IQR) Preadmission 32 (17-42)31 (20-43)36 (21-46) Mean (SD) score change -7.2 (16.1)-12.1 (13.8)-14.2 (13.5) P < 0.05 Main reason for transfer delays was administrative Observed trial treatment effect largely due to early transfer group of patients

21. (5 Gen Hosp; 7 CHs; n = 490) 1.Rehabilitation in the CHs was associated with a statistically significant improvement in medium term (6 month) independence outcomes – better EADL 2.CH associated with trends to fewer “poor” outcomes 3.Patient/carer experiences favour CH 4.Affordable cost……yes; £17,000 per (QALY) Young et al; JAGS 2007; 55; 1995 O’Reilly et al; Age Ageing (in press) Conclusions : Multi-centre RCT of post-acute care in community hospitals

22. Median LOS (IQR) 22 (11-45)20 (10-34) % readmissions 28%23% Median QALY value 0.270.20P=0.17 Mean (SD) cost per patient £8,946 (6,514) £8,226 (7,453) P=0.26 Incremental cost effectiveness ratio (ICER) £17,192 (£ per QALY) / Com HospGen Hosp Economic study 6 month results Societal perspective for health care affordability in England is responsibility of the National Institute for Health and Clinical Effectiveness (NICE) Health care systems and technologies considered affordable when ICER less than £30,000 Therefore in English NHS……..community hospital post-acute rehabilitation care would be considered cost-effective

23. Steering Board (tri-partite) Health, social services, LHBs Operational Team (Operational Manager) + Consultant Doctor, Consultant Nurse, Senior Social Worker Consultant Rehabilatationist Single point of referral = Admission avoidance = Early supported discharge = Chronic long terms conditions mgt = Independent living within the community Integrated Intermediate Care Model (Gwent) Generic Support Workers (Multi-disciplinary) PathContinence Cardiac failure 1. Chronic disease mgt- Joint day care Palliative care Wound mgt Stroke COPD Neuro degenerative Rapid response Chronic conditions specialists ACAT Reablement 2. Chronic conditions mgt- Mental Health (dementia) Expert patient scheme District nursing (generalist role) Assistive technology/ smart houses Community hospitals Frailty care model

24. Referral: Primary, secondary, social services, ambulance Single point of referral = Admission avoidance = Early supported discharge = Chronic long terms conditions mgt = Independent living within the community Level 1 services model - process Generic Support Workers (Multi-disciplinary) PathContinence Cardiac failure 1. Chronic disease mgt- Joint day care Palliative care Wound mgt Stroke COPD Neuro degenerative Rapid response Chronic conditions specialists ACAT Reablement 2. Chronic conditions mgt- Mental Health (dementia) Expert patient scheme District nursing (generalist role) Assistive technology/ smart houses Unified comprehensive assessment Frailty care model Community Hospitals

25. Gwent Schemes (I.C) Early Discharge SchemesMonthsNumbersBed Days SavedDifferential in Cost (a)Reablement Scheme: Blaina Gwent (Budget = £39800) (b) Mardy Park Rehab Service (Budget = £26300) 12 555 N=118 N = 8325 (Av. Bed per day 15 days) N = 1416 30 - 18 = 12 days served ↓ (Community (In this Scheme) Hospital) £2,497,500 (£300 per day in hospital) £167,088 (£150 per day) Admission Prevention Sch. (a)Rapid Response Scheme: Blaina Gwent (Budget = £247,014) (a)ACAT + Rapid response (Torfaen) (Budget = £455,690) 12 N= 574 518 Prevented. (90.24%) N = 965 876 Prevented. (90.77%) 518 x 7 days (3626) 876 x 7 days (6132 days saved) £1087,800 (£300 per day in hospital) £1,839,600 (£300 per day in hospital)

26. Activity Figures: Non Elective: Adult Medicine (Since 1999 till 2008 = 53% increase) RGHNHHLOS RGHLOS NHH 1999-2000 2002-2003 2005-2006 2007-2008 12902 14053 14046 13615 (+7.0%) Since 2000. 7351 9261 10728 13615 (+46%) Since 2000. 7.1 8.2 8.0 8.4 6.5 6.3 5.7 5.2 Reduction Of 90 Community Hospital Beds

27. Evidence-base for Intermediate Care: Conclusions………………………. 2. Most evidence for early discharge form of I.C. 1. Limited RCT evidence base BUT…. organisational factors are critical to success & clinical governance systems are needed to monitor outcomes 3. Evidence for HaH and CH intermediate care encouraging